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REVIEW ARTICLES
MILITARYMEDICINE,179,9:942,2014
ASystematicReviewofCognitiveBehavioralTherapy
for Depression in Veterans
Natalie E. Hundt, PhD*†‡; Terri L. Barrera, PhD*†‡; Andrew Robinson, MA*; Jeffrey A. Cully, PhD*†‡ Downloaded from https://academic.oup.com/milmed/article/179/9/942/4159550 by guest on 26 September 2022
ABSTRACT Research conducted in the civilian population demonstrates that cognitive-behavioral therapies are
effective for depression, but some evidence suggests that Veterans’ treatment response may differ from civilians. This
review examined cognitive-behavioral treatment (CBT) for depression in Veteran samples. A literature search for
treatment outcome studies with Veteran samples was conducted using PsycInfo, PubMed, and SCOPUS databases.
Nine studies met inclusion criteria and were assessed for methodological rigor (randomized controlled trials = 5;
open trials = 4). Controlled effect sizes were compared for randomized controlled trials, and pre–post effect sizes were
used to compare treatment groups across all studies. The open trials reviewed demonstrated large pre–post effect sizes,
though these studies were of lower methodological quality. CBT performed better than control treatment in only
two of five randomized controlled trials reviewed, a finding that contrasts with research in non-Veteran samples.
Possible reasons for these findings are discussed, including psychosocial factors that may influence the course of
depression treatment in Veterans. Additional high quality research is needed to conclusively determine if depression
treatment outcomes differ for Veterans and, if so, what modifications to current CBT protocols might enhance
response to treatment.
INTRODUCTION 12
interventions” or second-line treatments for depression. Fol-
MajorDepressiveDisorder(MDD)isoneofthemostcommon lowing the issuance of these clinical guidelines, the Veterans
psychiatric diagnoses among Veterans and active duty mili- Health Administration and the Department of Defense imple-
1–3
tary and is associated with impairments in a variety of mented programs to enhance access to and quality of depres-
4,5
domains. There is strong evidence that cognitive-behavioral sion care, including national “rollouts” of training and
treatments (CBT) for depression are effective in civilian popu- 13,14
facilitation for both CBT and ACT for depression. These
6–9 10
lations, and the American Psychological Association and guidelines and implementation efforts were primarily based
11
National Institute for Health and Care Excellence endorse on evidence from civilian populations, given the absence of
CBTfordepression. randomized controlled trials (RCTs) of CBT for depression in
Given the strength of the evidence supporting CBT as an Veterans or active duty military.
effective treatment for depression, the Department of Veterans Although the evidence supporting CBT as an effective
Affairs (VA)/Department of Defense issued clinical practice treatment for depression in civilians is robust, some research
guidelines strongly recommending CBT as a first-line treat- suggests that Veterans’ treatment response may differ from
12
ment for depression. Additionally, these guidelines identify that of civilians. Two meta-analyses of treatments for post-
two newer CBT-based treatments, behavioral activation and traumatic stress disorder (PTSD) found that Veteran status
acceptance and commitment therapy (ACT), as “promising or combat-related PTSD moderated treatment response, with
combat Veterans improving less than other patients with
*VAHSR&DHoustonCenter for Innovations in Quality, Effectiveness PTSD.15,16 Consequently, in 2007, the Institute of Medicine
and Safety, Michael E. DeBakey VA Medical Center, Houston, TX 77030. reported that current research is “inadequate to answer ques-
†Menninger Department of Psychiatry and Behavioral Sciences, Baylor tions about the interventions, settings, and lengths of treat-
College of Medicine, Houston, TX 77030. ment that are applicable in this specific population.”17(p11)
‡VA South Central Mental Illness Research, Education and Clinical
Center, Houston, TX 77030. Although there has been less investigation of the efficacy of
The views expressed reflect those of the authors and not necessarily the depression treatments in Veterans, there are, nevertheless,
policy or position of the Department of Veterans Affairs, the U.S. Govern- some data that CBT for depression may be less effective in
ment, or Baylor College of Medicine. None of these bodies played a role in this population.18
study design; in the collection, analysis and interpretation of data; in the
writing of the report; or in the decision to submit the article for publication. Disparities in treatment response may be related to a variety
doi: 10.7205/MILMED-D-14-00128 of factors. Veterans differ from civilians on a variety of
942 MILITARYMEDICINE,Vol.179,September2014
Systematic Review of CBT for Depression in Veterans
sociodemographic factors, including gender and age. VA and conducted a comprehensive literature search for treat-
national databases indicate that, of Veterans newly diagnosed ment trials testing CBT for depression. We did not limit our
with depression, approximately 90% are men, and the mean search to RCTs as there have been relatively few RCTs con-
19
age is 57. This is in contrast to community mental health ducted in Veteran and military populations. Treatments were
samples, which typically include a higher percentage of classified as cognitive behavioral if the study authors identi-
women and younger patients. Veterans may also suffer from fied the treatment as CBT, or if the psychotherapy used tech-
higherratesofmedicalandpsychiatriccomorbidityandgreater niques (e.g., behavioral activation, cognitive-restructuring,
20 mindfulness) that are widely recognized in the research liter-
severity of psychiatric symptoms than community patients.
21–23 ature as cognitive behavioral in nature. For inclusion, treat-
The high rates of comorbid PTSD in depressed Veterans
may also be related to poorer treatment response as PTSD- ments were required to specifically target depression or
related avoidance can interfere with patients’ ability to com- depression symptoms; interventions that focused on both Downloaded from https://academic.oup.com/milmed/article/179/9/942/4159550 by guest on 26 September 2022
plete and benefit from behavioral-activation exercises, and depression and a comorbid condition (e.g., substance use)
PTSD-related numbing may interfere with building rewarding were allowed. Inclusion criteria also required that all partici-
interpersonal relationships. Higher rates of medical comorbid- pants be Veterans or active duty military over the age of
ity in Veterans may interfere with treatment attendance, limit 18 years and either have a diagnosis of a depressive disorder
patients’ abilities to engage in behavioral activation, or other- or endorse clinically significant depressive symptoms (e.g.,
24 Beck Depression Inventory [BDI] score > 14 or Patient
wise complicate psychotherapy.
Additionally, for Veterans, extended deployments may Health Questionnaire [PHQ] score > 10). We did not exclude
cause readjustment stress, poor social support, and family studies that allowed participants to receive concurrent sup-
25,26
problems, and engagement in combat is itself a risk factor portive therapy and/or psychotropic medication since doing
27 so would have severely restricted the number of included
for the development of mental disorders. Veterans are
28,29 studies. There were no restrictions on comorbid psychiatric
at higher risk of suicide than non-Veterans, as well as at
30,31
higher risk of being homeless. Female Veterans have diagnoses. Finally, we excluded studies published in a
higher lifetime rates of abuse and victimization than civilian language other than English.
32,33
women. These factors may complicate Veterans’ clinical
presentation and negatively affect treatment response. StudyQualityAssessment
In summary, a comprehensive review on the effectiveness
of psychotherapy for depression in Veterans and military Weassessed the quality of each of the included studies using
populations is needed to fully understand the potential bene- the “Psychotherapy outcome study methodology rating form”
¨ 34
fits and limitations of these treatments. If such treatments are (POMRF),describedbyOst. Thisscaleconsistsof22items
of limited effectiveness for Veterans and military personnel, that examineindividualmethodologicalelements(i.e.,descrip-
identification of factors that restrict treatment outcomes and tion of sample characteristics, psychometric properties of
exploration of treatment enhancements would be needed. outcome measures, research design, statistical analysis, and
therapist training and adherence). Each item is rated on a
METHODS 3-point scale from 0 to 2, where 0 = Poor, 1 = Fair, and 2 =
Good. Overall quality scores range from 0 to 44, with higher
DataSources scores indicating greater methodological rigor. Each study
We searched PsycINFO, PubMed, and SCOPUS for treat- was rated by two independent reviewers. Discrepancies in
ment outcome studies of CBT for depression, published from ratings were resolved through discussion and consensus with
each database’s first allowable search date through August a third reviewer.
2013. The following search terms were used: “veteran”
or “military” to identify the population of interest; “depress” or RESULTS
“depression” to identify the target disorder; and “CBT,” An initial review of relevant abstracts using the aforemen-
“cognitive behavioral,” “cognitive therapy,” “behavioral ther- tioned criteria yielded 24 studies for potential inclusion (Fig. 1).
apy,” “behavioral activation,” “ACT,” “acceptance and com- Ofthese, nine studies met final inclusion criteria (Table I).
mitment therapy,” “problem-solving therapy,” “self-control Theprimary reasons for exclusion were (1) the study’s inclu-
therapy,” “self-management therapy,” or “psychotherapy” to sion criteria did not require a diagnosis of a depressive dis-
identify studies that included CBT. We also reviewed the refer- order or sufficient depression symptom severity (n = 9),
ence section from each identified included study to identify (2) the treatment did not target depression specifically
other potential studies. (n = 3), and (3) the treatment was deemed to be not cognitive
behavioral (n = 3). We classified the 9 included studies
StudySelection according to their design: randomized trials for depression
Weelected to focus exclusively on treatments broadly cate- alone (n = 1), open trials for depression alone (n = 2), imple-
gorized as CBT to reduce the confounds that would result mentation trials of depression alone (n = 2), and RCTs for
from comparing multiple different treatment orientations depression and comorbid disorders (n = 4).
MILITARYMEDICINE,Vol.179,September2014 943
Systematic Review of CBT for Depression in Veterans
Downloaded from https://academic.oup.com/milmed/article/179/9/942/4159550 by guest on 26 September 2022
FIGURE1. Included and excluded studies.
OverviewofIncludedStudies abuse (n = 2), and anxiety (n = 1). We included a variety
Table I provides an overview of the nine included studies. of broadly CBT-based treatments, including traditional CBT
The total number of participants was 1,683 Veterans, (n = 6), behavioral activation (n = 1), ACT (n = 1), and self-
although individual study ns ranged from 8 in a small open control therapy (n = 1). The number of sessions specified by
trial to 791 in a large nonrandomized implementation trial. treatment protocols ranged from 4, in an integrated primary
Nostudy specifically examined active duty military patients. care study, to 36, in a dual-diagnosis CBT protocol.
Seven studies required a diagnosis of a depressive disorder,
although two of these used diagnoses from the patient’s med- StudyQuality
ical record rather than a standardized interview or assess- Study quality ratings ranged from 15 to 32 on the POMRF,
ment. In contrast, two studies used symptom severity on the with a mean study quality of 21.4 (SD = 5.3). Although the
BDI, second edition (BDI-II) or Center for Epidemiologic POMRFdoesnotspecifycutoffsfor sufficient methodological
Studies Depression Scale (CES-D) as inclusion criteria. rigor, the mean quality of the current studies is lower than
Changesindepressionsymptomswereprimarilyassessedwith ¨ 34
those in Ost’s review of CBT outcome trials, which found
the BDI-II, Hamilton Depression Scale (HAM-D), Hospital that the mean study quality was 27.8 (SD = 4.2) on the same
Anxiety and Depression Scale (HADS), or PHQ-9; although rating scale. An examination of ratings on quality domains
one study used the CES-D. Patients were recruited from the indicated that, of the included nine studies, only five (55%)
following VA settings: community-based outpatient clinics used randomization, and only one (11%) employed evalua-
(n = 2 studies), integrated primary care (n = 2), a dual-diagnosis tors masked to condition. Of the randomized trials, one used a
clinic (n = 2), a PTSD clinic (n = 1), or multiple VA settings waitlist control, one used a psychoeducational group, one
(n = 2). Four studies specifically examined depression comor- used treatment as usual, and two used 12-step facilitation.
bid with other disorders, including PTSD (n = 1), substance Six (66%) used a structured interview to ascertain depression
944 MILITARYMEDICINE,Vol.179,September2014
Systematic Review of CBT for Depression in Veterans
Scale;Scale;
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MILITARYMEDICINE,Vol.179,September2014 945
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